In the United States, graduates from Associate Degree in Nursing programs (ADN) and Bachelor of Science in Nursing (BSN) programs are both licensed as RNs and work under the same scope of practice (National League for Nursing, 2010a). In 2010, the Institute of Medicine recommended that the percentage of BSN-prepared RNs at the bedside should increase to 80% by the year 2020 (Institute of Medicine, 2010). The recommendation is a culmination of growing evidence that suggests an association between BSN-prepared RNs nurses and improvements in patient outcomes (Aiken, 2014; Aiken et al., 2011; Blegen, Goode, Park, Vaughn, & Spetz, 2013; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Lee, Staffileno, & Fogg, 2013; National League for Nursing, 2010b). These studies differentiate between ADN- and BSN-prepared nurses; however, they do not factor in that BSN nurses might have completed different types of BSN education, such as an ADN-to-BSN completion program.
National attention to increase the number of BSN-prepared RNs at the bedside has resulted in near exponential growth in the number of ADN-to-BSN completion programs (American Association of Colleges of Nursing, 2017a). The programs are designed to assist ADN-prepared RNs to “develop stronger clinical reasoning and analytical skills” (American Association of Colleges of Nursing, 2017a, para. 4). In 2013, 40% of all BSN graduates actually completed ADN-to-BSN degrees, as opposed to the 4-year or accelerated bachelor's degree (Future of Nursing Campaign for Action, 2015).
Research suggests graduates from ADN-to-BSN programs view their education as improving their patient care practices and perceive their education to be a worthwhile endeavor; however, study participants were not explicit about how their BSN education may have influenced their ability to keep patients safe (Adorno, 2010; Anbari, 2015; Delaney & Piscopo, 2007; Einhellig, 2012; Morris & Faulk, 2007; Rush, Waldrop, Mitchell, & Dyches, 2005). Therefore, the purpose of this study was to identify what component of an ADN-to-BSN program graduates perceive as having contributed to their ability to keep patients safe.
This was a qualitative, descriptive study involving semistructured interviews of ADN-to-BSN graduates about their BSN education. Specifically, participants were asked to describe whether they thought the ADN-to-BSN degree or components of their education contributed to their ability to keep patients safe. The research question that guided this study was: What components of their coursework do ADN-to-BSN graduates perceive as having contributed to their ability to keep patient safe?
After obtaining University of Missouri Health Sciences institutional review board approval, recruitment from one large 600-bed hospital system was conducted via the e-mailed weekly nursing newsletter. This method yielded three ADN-to-BSN participants. Five additional participants were recruited by e-mailing recent ADN-to-BSN graduates from two large midwestern universities. Both purposive and snowball sampling were used to meet inclusion criteria. The inclusion criteria were that the participants had adult acute or critical care work experience to ensure they were familiar with similar hospital work environments. In addition, using Benner's (2001) novice to expert continuum, participants who had been RNs for less than 2 years and longer than 6 years were excluded to somewhat control for years of experience influencing their patient safety abilities (Benner, 2001). Benner's (2001) theory states that RNs, regardless of education, practice nursing and improve nursing skills on a continuum from novice to expert. Therefore, nurses having worked 2 to 5 years were anticipated to have similar skills (Benner, 2001).
Participants were either interviewed in person at an agreed upon location (n = 4) or by telephone at an agreed upon time (n = 4). Together, each participant and the principle investigator (A.B.A.) reviewed an institutional review board approved waiver of documentation of consent prior to beginning the interview. A waiver of documentation of consent was used because of the low risk to participants, and participation alone indicated consent. After reviewing the waiver, participants completed a demographic form about their nursing education and work experiences, as well as general characteristics such as gender, age, and race/ethnicity.
Transcriptions of the recorded interviews were analyzed using content analysis and coded using emerging themes and categories (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005; Vaismoradi, Turunen, & Bondas, 2013). Content analysis is often used to identify recurring themes or trends and was well-suited for analyzing the participants' narratives about their education (Elo & Kyngäs, 2008; Vaismoradi et al., 2013). All coding and analysis took place in Dedoose©, an online qualitative software created by researchers at the UCLA Center for Culture in Health. Using content analysis and Dedoose allowed for participants' descriptions of their educational experiences to be categorized and simplified. Trustworthiness and rigor of the analysis process were ensured by maintaining a detailed audit trail outside of Dedoose and confirming the objectivity and accuracy of the emerging themes with PhD-prepared nurse researchers who have extensive qualitative method research experience (Crabtree & Miller, 1992).
Eight ADN-to-BSN graduates participated in the study. Among these participants, the mean years of experience was 3.9 years, all were White/Caucasian, and three identified as male (37%) and five as female (63%). The mean age of this group was 31.4 years. Four (50%) of the ADN-to-BSN graduates had critical care experience, and four (50%) had acute care experience. All the participants attended ADN-to-BSN programs that included online instruction for all of the coursework. However, four of the participants' programs also included required clinical hours for some courses. These clinical rotations focused on nursing management–leadership and community nursing.
Three themes emerged from the data, including: (a) An Unaltered Approach to Keeping Patients Safe; (b) Experience as an ADN Matters; and (c) BSN Degree as a Stepping Stone. Each theme is explained and discussed below.
An Unaltered Approach to Keeping Patients Safe
When asked about their BSN coursework that influenced their ability to keep patients safe, all participants said in general there were none. However, several participants did state that the additional coursework made them think about patient care differently, in that they now approached patient care with a “greater scope” or were now more accepting of “others' viewpoints.” Participants who acknowledged that they approached patient care differently cited an appreciation for their cultural awareness and research coursework as a means to expand their thinking. They also mentioned an improved understanding of nursing management and leadership via their management courses. However, although participants discussed an improved understanding based on their BSN coursework, they were unable to articulate or provide explicit examples of how their expanded understanding influenced their ability to keep patients safe.
When asked specifically about influencing their approach to patient safety, one participant did say that the BSN degree gave him a broader understanding of the complexity of health care; however, the degree did not necessarily influence his ability to keep patients safe. He stated:
- I don't feel, as far as the safety's concerned, could change much, but it [BSN education] gives me a better understanding of...not only does that person get hurt, but then you've also got legal issues,… it gives me a better understanding of everything that it entails.
The idea that the BSN education did not influence their ability to keep patients safe was also expressed by another participant who stated that the “degree doesn't change how you are as a nurse.” Similarly, another participant commented:
- My BSN and my experience didn't change any nursing practice or safety or medication administration. I mean, I didn't give one med[ication] I don't think during my BSN completion. So it was, it really was a paperwork and a BlackBoard discussion and a homeless shelter clinical.
This participant went on to explain “as much as they [nurse educators] think it is, that's not teaching me about safety. I want to be in the ICU hanging epi[nephrine] and dobutrex…[critical intravenous medications].”
Experience as an ADN Matters
Participants consistently stated that their ability to keep patients safe was influenced more by experience and practice, rather than advanced education. When asked if his BSN education influenced the way he processed a patient safety event, one participant stated:
- I was already a nurse practicing…. I'd been a nurse for three years so, which isn't a long time, I get that…my BSN didn't change any kind of patient safety.
Experience, as opposed to the BSN education, was emphasized again by another participant, who stated:
- I think my real experience came from working, from... actually having these experiences with patients, and I think when I was doing my BSN, luckily I already [had] my [ADN] and was already a practicing nurse so that kind of made the BSN part easier.
An additional participant stated that she did not think the ADN-to-BSN education was geared toward patient care and that it was her ADN education that taught her the “nitty-gritty” and got her “on the [patient care] floor…working as a nurse.”
BSN Degree as a Stepping Stone
Participants chose to return to school for similar reasons. First, all perceived their BSN degree as a stepping stone to the next level of education and the next step in a career. Participants commented:
- I just like to excel at everything I do.… I would like to be in management.
- I do want to be the best, you know, I can be, and I want to build my career
Second, participants shared a sense of accomplishment and satisfaction, as reflected by this example:
The satisfaction of having…another token, it's another badge… I didn't do it for the money. The money's not there, but I did it... to go on, and the satisfaction.… It [the BSN degree] puts you in another level.
Findings from this study confirm findings by Matthias and Kim-Godwin (2016), who reported ADN-to-BSN students as not anticipating that their BSN education would change their nursing practice because their ADN education already taught them to provide safe care at the bedside. In addition, this study supports earlier findings about ADN graduates' completion of their BSN degree for career advancement and perhaps graduate education (Anbari, 2015). However, only one participant in the current study recognized that the educational process itself was a benefit. Only one participant recognized that the educational process itself was a benefit.
Recently, the percentage of ADN-prepared RNs employed by hospitals has decreased, whereas the percentage of BSN-prepared RNs nurses has increased (Auerbach, Buerhaus, & Staiger, 2015). Auerbach et al. (2015) cited the 2010 Institute of Medicine report on the Future of Nursing as a “tipping point” (p. 12) that continues to influence employers' hiring preferences. The initial recommendations to increase the number of BSN-prepared RNs at the bedside were influenced by the connection between patient outcomes and the number of BSN-prepared RNs at the bedside (Aiken, 2014; Aiken et al., 2011). That is, BSN-prepared RNs receive a different, higher level of education that prepares them to better meet patient needs and ultimately keep patients safer (Shalala et al., 2010). Yet, when participants from this study returned for a BSN degree, they were motivated by career advancement and did not perceive overt improvements in their skills or abilities to keep patients safe, nor did this group make any reference to the evidence about improvements in patient outcomes with an increased percentage of BSN-prepared RNs at the bedside.
It seems that ADN nurses in this study returned to obtain their BSN degree to conform to recommendations and requirements they perceived as necessary for job security and advancement, while remaining skeptical of its theoretical rationale—namely, to improve patient outcomes. There are three possible explanations for this apparent discrepancy. First, it is possible that the ADN-to-BSN programs indeed do not appreciably change nursing practice to achieve better patient outcomes. ADN-to-BSN programs are heterogeneous (Kumm, Godfrey, & Martin, 2014; McEwen, White, Pullis, & Krawtz, 2012; RN to BSN, 2015), and even when they have common elements, these elements may not address the reasons for the difference in outcomes between ADN- and BSN-prepared RNs nurses. Those reasons, of course, remain unknown.
Second, ADN-to-BSN programs may improve nursing practice for their graduates, although these improvements are difficult for the nurses to perceive. Perhaps it is a different way of thinking, awareness of the big picture of patient care, or more confidence. These differences have been stated as benefits of graduating from an ADN-to-BSN program, although their relationship to improved outcomes and safety remains unclear (Adorno, 2010; Anbari, 2015; Delaney & Piscopo, 2007; Einhellig, 2012; Morris & Faulk, 2007; Rush et al., 2005). For example, one participant noted that the BSN degree expanded his understanding of legal and insurance issues; however, he did not directly associate that expanded knowledge to patient safety. He could have been looking for new discrete bits of knowledge about health care and nursing, but the improvement was more nuanced and ineffable.
Finally, ADN-prepared RNs who may be motivated to pursue the BSN degree are a subgroup of nurses that already practices at a higher level compared with other ADN graduates. In that case, the BSN degree may indeed advance their career or act as a stepping stone for a promotion or further education, without changing their safety outcomes. This is another gap in knowledge that merits further research.
There are limitations worth acknowledging about this qualitative study that limit the transferability of findings. First, the sample size of eight RN participants is small and therefore, may not reflect the larger population of ADN-to-BSN graduates. That said, this is somewhat mitigated by the fact that the eight participants attended five different ADN-to-BSN completion programs. Variability among these five programs can be assumed, making it possible that they are representative of ADN-to-BSN programs at large. Second, although this study accounted for time between ADN entry into practice and BSN completion, it is possible that time in practice prior to completing their BSN degree may have influenced their perceptions.
The call to increase the number of BSN-prepared RNs nurses at the bedside is supported in the evidence and noteworthy of pursuit. However, as ADN-to-BSN programs increase in numbers to meet this demand, the outcomes for graduates need to be considered. Moreover, the benefits of a BSN education beyond that of job security or career advancement may need to be emphasized by both those who educate nurses, and those who employ them.
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